When Does Medicare Cover Contact Lenses?

Medicare is a federal health insurance program for individuals aged 65 or older and certain younger people with disabilities. While Medicare generally does not cover routine vision care, including contact lenses, specific situations and alternative options for coverage exist.

Original Medicare’s Vision Coverage

Original Medicare, composed of Part A (Hospital Insurance) and Part B (Medical Insurance), generally covers medically necessary vision services rather than routine eye care. Part A provides coverage for inpatient hospital care, which could include eye surgery if a hospital stay is required.

Part B covers outpatient medical services, including doctor visits and certain diagnostic tests related to eye conditions. This includes examinations and treatments for specific eye diseases like glaucoma, cataracts, and macular degeneration. Part B also covers a yearly eye exam for individuals with diabetes to check for diabetic retinopathy, and annual glaucoma tests for those at high risk. These are considered medical treatments aimed at diagnosing or treating an illness, not routine vision correction.

Contact Lens Coverage Under Original Medicare

Original Medicare does not provide coverage for routine contact lenses, eyeglasses, or routine eye exams. For general vision correction, individuals typically pay out-of-pocket for these items. However, Medicare Part B offers a specific exception for contact lens coverage.

If contact lenses are medically necessary and prescribed by a doctor following cataract surgery that implanted an intraocular lens, Medicare Part B may cover a portion of the cost. This coverage is for one set of corrective lenses, which can be contact lenses or eyeglasses with standard frames, after each covered cataract surgery. Individuals are responsible for 20% of the Medicare-approved amount after meeting their Part B deductible. Any additional costs for upgraded features are not covered. The supplier of the contact lenses must be enrolled in Medicare for coverage to apply.

Medicare Advantage Plans and Contact Lenses

Medicare Advantage Plans, also known as Part C, are offered by private companies approved by Medicare. They provide an alternative way to receive Medicare Part A and Part B benefits. These plans must cover everything Original Medicare covers, but they often include additional benefits that Original Medicare does not, such as routine vision care. Many Medicare Advantage plans offer coverage for routine eye exams and may include allowances or coverage for contact lenses or eyeglasses.

The specific vision benefits, including coverage for contact lenses, can vary significantly among different Medicare Advantage plans. Some plans might provide a fixed allowance for eyewear, while others may cover a percentage of the cost. Individuals should review the details of specific plans to understand their coverage for contact lenses and any associated costs or limitations.

Other Options for Contact Lens Coverage

For individuals without contact lens coverage through Medicare or Medicare Advantage, several other avenues can help manage costs. Standalone vision insurance plans are a common option, specifically designed to cover routine eye exams, contact lenses, and eyeglasses. These plans can be purchased privately to supplement Medicare coverage.

Another approach involves utilizing tax-advantaged accounts like Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs). These accounts allow individuals to set aside pre-tax money to pay for eligible medical expenses, including prescription contact lenses and eye exams. FSAs typically require funds to be used within a plan year, while HSAs allow funds to roll over annually, offering long-term savings potential for vision care. Additionally, some retail stores and membership programs offer discounts on eye exams and eyewear, providing further opportunities for savings.